• Client Implementation Request Form

    Client Implementation Request Form

  • The following information is required to create a new hire record for your organization. This information is handled with HIPAA Compliance. Please do not print this form and attempt to hand-write the information in. Your signature will be captured electronically at the end of this form and you will receive a confirmation email upon submission. Thank you.

  • Today's Date
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    2 digit month, 2 digit day, 4 digit year

  • CLIENT OVERVIEW

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  • LEAVE

  • Will the client be offering leave to the employees:*
  • Paid Time Off
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  • PAID HOLIDAYS

  • MEDICAL BENFITS PLANS

  • Do you wish to offer Group Benefits to your Employees ? (Full-time EEs Only)
  • Full-time Employees are eligible for health benefits in the US and Employers are required to contribute towards their medical premiums. Please list your contribution amount(s) below for each coverage tier. (NOTE: The minimum amount for 2023 is $362.42 , there is no maximum.)
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  • ANCILLARY & SUPPLEMENTAL BENEFIT PLANS

  • 1. Do you wish to offer your Employees DENTAL benefits?*
  • 1a. Please choose which DENTAL benefit plans you wish to offer your Employees:
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  • 2. Do you wish to offer your Employees VISION benefits?*
  • 2a. Please choose which VISION benefit plans you wish to offer your Employees
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  • 3. Do you wish to offer your Employees Short Term Disability (STD) benefits?*
  • 4. Do you wish to offer your Employees Long Term Disability (LTD) benefits?*
  • 5. Do you wish to offer your LIFE / AD&D benefits?*
  • 6. Do you wish to offer Guardian's Supplementals benefits - ACCIDENT, HOSPITAL INDEMNITY, and CRITICAL ILLNESS?*
  • Will this Employee be eligible for a 401(k) / Retirement / Pension Plan?

  • Please send your new employee the following link to complete. Please feel free to click on the link to view the simple form your new hire will complete for our employment purposes.

    EMPLOYEE NEW HIRE INFORMATION FORM

    Thank you for choosing Lightsource Global for your EOR needs. We appreciate your partnership.

  • CERTIFICATION & SIGNATURE

    The undersigned attests that the information contained in this document is true and correct to the best of the undersigned’s knowledge. The undersigned understands this document is not a contract for service or employment nor will it bind coverage of any kind. This information is strictly governed by HIPAA compliance rules. In the event that information has been intentionally omitted or misrepresented, the employer of record may deny or limit services. I will notify Lightsource Global of any changes to the information imparted here that occur after signing this form.

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